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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 08/29/2024
Date Signed: 10/21/2024 06:36:57 PM

Document Has Been Signed on 10/21/2024 06:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR/
DIRECTOR:		MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 82DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Terri Harris, Concierge TIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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*Amended report*
08/29/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Terri Harris, Concierge, where LPA explained the purpose of the visit. The facility is licensed to serve residents age range 60 and over, 110 non ambulatory, of which 12 may be bedridden. The facility has an approved hospice waiver for 20, and for delayed egress. There are 13 residents receiving hospice services.

The facility consists of (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of (4) cottages dedicated to assisted living residents and (2) cottages dedicated for memory care residents. Below is a summary of what was observed during today's visit: LPA conducted a tour of the interior and exterior areas of the facility, there are no pools or bodies of water on the premises.

LPA conducted a review of both staff and record files. LPA reviewed (6) resident files that were observed to have the required documents such as medical assessment, needs and services appraisal. Regarding staff files, all staff present at the facility were observed to have obtained criminal record clearance, and to be associated to the facility however, there was no proof of valid CPR certification in the (6) files reviewed deficiency cited. The staff files reviewed were not observed to have any updated required training. In addition LPA observed for the facility to have a change of administrator. LPA discussed that a request should be submitted for the facility administrator to be updated with the regional office.

The kitchen which is in the main building was observed to be clean, and clutter free. There was plenty of cookware, dishes and utensils to serve the residents in care. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
VISIT DATE: 08/29/2024
NARRATIVE
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The resident bedrooms were observed to be clean and odor free, the cottages were at a comfortable temperature. The hot water was tested and found to be within regulatory limits measuring 105.4-114.2 degrees Fahrenheit. The medications are locked inside medication carts. The facility uses electronic Medication Authorization Records (MAR)s. Each cottage was observed to have a fully charged fire extinguisher.

The smoke and carbon monoxide detectors were unable to be tested at the time of LPAs visit as there was not a staff on grounds that knew how to test the devices. LPA conducted a review of the fire inspections log and observed that there is no record that the facility has been conducting emergency disaster drills on a quarterly basis. The last drill documented was an elopement drill that was conducted on 5/19/22. deficiency cited.

Based on today's inspection citations were issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, 809D, appeal rights, and LIC9098-Proof of Corrections form was reviewed and provided to Terri Harris.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/29/2024 04:47 PM - It Cannot Be Edited


Created By: Javina George On 08/29/2024 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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The licensee agrees to enroll, and have 6 out of 6 staff complete CPR training. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 times, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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The licensee agrees to conduct an emergency disaster drill and document it. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/29/2024 04:47 PM - It Cannot Be Edited


Created By: Javina George On 08/29/2024 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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The licensee agrees to obtain liability insurance. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2024 06:37 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/29/2024 06:36 PM


Created By: Javina George On 08/29/2024 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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THERE IS NO POC DUE AS THE PROPER DOCUMENTATION WAS LOCATED VERFYING THAT R1 HAS PROPER FINGERPRINT CLEARANCE AND IS ASSOCIATED TO THE FACILITY.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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